F0760

D

Failure to Administer Insulin and Antihypertensives as Ordered

Dayton, Ohio Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications, including insulin and blood pressure medications, were administered as ordered for one resident. The resident was admitted with diagnoses including acute and chronic respiratory failure, dysphagia, COPD, DM, and ESRD, and required assistance with most activities of daily living. Physician orders included midodrine with instructions to hold if systolic blood pressure (SBP) was greater than 110, metoprolol with instructions to hold if SBP was less than 100 or diastolic blood pressure (DBP) was less than 60, scheduled insulin lispro before meals and at bedtime, Lantus twice daily, and multiple other medications via PEG-tube and inhalation. The facility’s policy on administering medications required that medications be administered safely, timely, and in accordance with prescriber orders, including any required time frames.

Medical record review showed that the December Medication Administration Record (MAR) contained no documentation that medications, including insulin, were administered as ordered on multiple specific dates in December. Further review of the January MAR showed that blood pressure medications (metoprolol and midodrine) were administered outside of the ordered blood pressure parameters on multiple specific dates in January. In an interview, an RN confirmed the absence of documentation supporting that the resident received medications, including insulin, on the identified December dates and confirmed that blood pressure medications were given outside the ordered parameters on the identified January dates. These findings demonstrated that the facility did not follow physician orders or its own medication administration policy, resulting in significant medication errors for this resident.